| NPI | 1215381751 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA2990) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY TC192) |
| 363AM0700X Physician Assistant, Medical | |
| Enumeration Date | 2016-04-21 |
| Last Update Date | 2025-09-24 |